Jake is a 6-week-old male infant hospitalized with the diagnosis of Tetralogy ofFallot (TOF).Jake was full-term when he was born without any complications. He was seen at his pediatrician’s office because Jake’s mother was worried that he was not gaining weight and was having difficulty sucking on the bottle during feedings.The pediatrician noted that Jake had a murmur and referred him to a pediatric cardiologist at a pediatric care facility. He is admitted with the diagnosis of TOF and CHF.

You are the admitting nurse and do a complete physical assessment on Jake. The following are your findings. Please explain if these are expected or unexpected and why.

Apical pulse: 165

Respiratory rate: 66

CHAPTER 11 Pediatric Cardiac Functioning

Lung sounds/respiratory rate, effort, accessory muscle use status

Heart sounds-gallop rhythm

Weak suck

Capillary refill longer than three seconds

Weight: 3.1 kg

You implement care interventions to improve cardiovascular functioning. Provide a rationale for the following care interventions that are incorporated into Jake’s plan of care and are shared with his parents:

You enter Jake’s room and find him to have circumoral cyanosis, a sweaty forehead, and a heart arte of260 beats/minute, and he is limp. Describe your nursing actions beginning with the most important to ensure Jake’s physical safety.

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